Nokea
The nurse is caring for a client who is in restraints due to violent behavior. The client states, 'I am a magician; I can get out of anything. There could be trouble now!' Which of the following actions would be most appropriate for the nurse to take?
- A. Notify other staff members that assistance is needed.
- B. Ask the client, 'Can you tell me why you think you are a magician?'
- C. Encourage discussion of the client's current feelings.
- D. Ask the client, 'What kind of trouble are you thinking about?'
Correct Answer: A
Rationale: The client's statement suggests a potential intent to escape restraints, posing a safety risk, so notifying staff for assistance is the priority.
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The nurse is caring for a woman who is admitted for a hysterectomy. The woman does not speak English. No staff members speak the client's language. Which approach by the nurse would be most appropriate when communicating with the client about her care before and after the surgery?
- A. Ask the woman's 8-year-old daughter who speaks English to interpret.
- B. Draw pictures and gesture when speaking to the client.
- C. Speak very slowly when giving the client instructions.
- D. Request an interpreter from social services.
Correct Answer: D
Rationale: The nurse should request an interpreter from social services to ensure accurate communication. Using a child to interpret is inappropriate due to medical terminology and privacy concerns. Pictures, gestures, or slow speech in English are insufficient for surgical care discussions.
A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to reinforce which instruction to the client?
- A. Avoid a high-potassium diet
- B. Exercise regularly and maintain a high-fiber diet
- C. Maintain oral hygiene
- D. Report excessive urination and increased thirst
Correct Answer: D
Rationale: Lithium can cause polyuria and polydipsia due to its effect on renal function. These symptoms may indicate lithium toxicity or diabetes insipidus, which require immediate medical attention.
Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing
- A. This position of my lips helps to keep my airway open.
- B. I can expel more when I pucker up my lips to breathe out.
- C. My mouth doesn't get as dry when I breathe with pursed lips.
- D. With prolonging breathing out with pursed lips the little areas in my lungs don't collapse.
Correct Answer: D
Rationale: Clients with chronic obstructive pulmonary disease have difficulty exhaling fully as a result of weak alveolar walls. Alveolar collapse can be avoided with the use of pursed-lip breathing.
A client is scheduled for an elective laparoscopic prostatectomy in the morning. The practical nurse should notify the registered nurse about which of the following assessment data as soon as possible before surgery?
- A. INR level
- B. platelet count
- C. hemoglobin and hematocrit levels
- D. temperature 100.4 F (38 C) with cough
Correct Answer: D
Rationale: A temperature of 100.4 F with cough suggests a possible infection, which could contraindicate surgery due to increased risk of complications.
The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? Select all that apply.
- A. Avoid annual influenza vaccination
- B. Avoid situations that cause physical and emotional stress
- C. Avoid sun exposure and ultraviolet light when possible
- D. Notify the health care provider if you have fever
- E. Use antibiotic soap to cleanse skin rashes
Correct Answer: B,C,D
Rationale: Stress, sun exposure, and infections can exacerbate lupus. Influenza vaccination is recommended, and antibiotic soap is unnecessary.